Linkages between child abuse and attention-deficit/hyperactivity disorder in girls: Behavioral and social correlates☆
Introduction
The behavioral sequelae of child abuse and the symptoms and outcomes of children with attention-deficit/hyperactivity disorder (ADHD) share many features, including aggression and externalizing behavior, depression, and cognitive difficulties (e.g., Ethier, Lemelin, & Lachorite, 2004; Mannuzza & Klein, 1999). This overlap has sparked a recent debate as to the possible association between ADHD and child abuse (Ford et al., 2000, Wozniak et al., 1999), which raises issues of (a) the possible etiologic and exacerbating role of abuse in the development of ADHD and (b) the potential for abuse-related post-traumatic responses being misdiagnosed as ADHD. Our key objectives were to examine whether girls with ADHD were at increased risk of having histories of abuse and to assess whether those with abuse histories may constitute a distinct subgroup. We focus on the understudied population of girls with ADHD, given the clinical and conceptual importance of this group (Hinshaw & Blachman, 2005). Our objective is not to investigate the prevalence of abuse within a normative sample (e.g., Finkelhor, Ormrod, Turner, & Hamby, 2005) but, within a clinical sample, to examine clinical presentation and levels of crucial impairments when abuse and ADHD co-occur. We examined girls with ADHD because of the underrepresentation of females in extant research and because of the availability of the large data base that we have gathered on a well-characterized female sample (Hinshaw, 2002).
Increased aggression and externalizing problems, including hostility, difficulty with anger management, impulsivity, and physical attacks (Widom, 1997) are clearly linked to abuse (Cicchetti, Rogosch, Lynch, & Holt, 1993; Deater-Deckard & Dodge, 1997; Margolin & Gordis, 2000; Osofsky, 2003, Widom, 1997). Physical abuse has been most strongly and specifically linked to externalizing problems (Margolin & Gordis, 2000); sexual abuse has been more directly linked to childhood PTSD symptoms and later internalizing symptoms (Kendall-Tackett, Williams, & Finkelhor, 1993; Whiffen & MacIntosh, 2005). Yet sexual abuse predicts such specific externalizing behaviors as sexualized talk, preoccupation with sexual themes, sexual aggression toward other peers, and provocative behaviors at early ages, collectively termed “sexual acting out,” (Gil & Johnson, 1993; Margolin & Gordis, 2000).
Next, abuse is often damaging to a child's self-perceptions and perceptions of the world, resulting in learned helplessness, anxiety, and depression (Kazdin, 1985), even to the point of increased self-destructive and suicidal behavior (Widom, 1997). Abused children also show evidence of poor social interactions and peer relationships. They are rated by their peers as more rejected, less popular, and more disruptive than children who have not been abused. Parents and teachers also rate abused children as socially rejected. Finally, abuse (Osofsky, 2003, Widom, 1997) and neglect (Margolin & Gordis, 2000; Osofsky, 2003) have been linked to both poor academic functioning and delayed cognitive development. On tests of verbal ability and comprehension, both physically abused and neglected children tend to score lower than non-abused comparison children. In sum, abused children present with externalizing and internalizing difficulties, compromised peer relations, and academic/cognitive impairments, yet specific mediators of such associations have yet to be elucidated.
ADHD is a childhood disorder characterized by impairing and developmentally extreme levels of inattention, impulsivity, and hyperactivity and yielding a prevalence of 3–7% (American Psychiatric Association, 2000). It is predominantly a male disorder, with male to female ratios approximating 3:1 in the population at large (Hinshaw & Blachman, 2005). The study of ADHD has been overwhelmingly based on male samples, with focus on girls emerging relatively recently (Arnold, 1996; Gaub & Carlson, 1997; Hinshaw & Blachman, 2005).
ADHD affects children in many domains, including those that closely parallel the above-noted examples related to abuse: externalizing difficulties (Hinshaw, 1987), internalizing problems (Jensen, Martin, & Cantwell, 1997), compromised peer relationships (Hinshaw & Melnick, 1995), and problems in cognitive ability/academic performance (Hinshaw, 1992). The extensive literatures on each of these domains of impairment are vast. Indeed, the impairments related to ADHD are substantial and rates of comorbidity with both disruptive and internalizing disorders are far above chance (Angold, Costello, & Erkanli, 1999). Furthermore, peer rejection places children at substantial risk for continued social problems, academic underachievement, and behavioral problems (Parker & Asher, 1987), meaning that the impairments related to ADHD are probably overdetermined.
ADHD is a condition for which high rates of heritability and evidence of neurobiological underpinnings strongly suggest neurodevelopmental origins (Tannock, 1998). This assertion is not meant to imply that school and family environments are unimportant in the development or maintenance of ADHD (Hinshaw, 1999); rather, it indicates that parenting is not likely to be a primary cause of ADHD. In addition, given the genetic underpinnings of many cases of ADHD, biological parents of children with ADHD are likely to show impulse control and attentional problems themselves (see review in Johnston & Mash, 2001), possibly increasing the likelihood of abusive behavior.
A substantial literature reveals that parents of children with ADHD experience more stress and more dysfunctional parent/child interaction styles than do parents of children without ADHD (Anastopoulos, Guevremont, Shelton, & DuPaul, 1992; Anderson, Hinshaw, & Simmel, 1994; Fischer, 1990; see review in Johnston & Mash, 2001). Furthermore, parents of children with ADHD report increased feelings of self-blame, incompetence, depression, and isolation (e.g., Nigg & Hinshaw, 1998). Not surprisingly, mothers of hyperactive children are separated or divorced more frequently than mothers of children without ADHD (Fischer, 1990).
We have asserted that abuse and ADHD share the common features of externalizing and internalizing behavior problems, peer rejection, and cognitive difficulties. Furthermore, child abuse is defined by inappropriate reactions on the part of adults (often parents) against children, and families of children with ADHD are marked by dysfunctional interactional patterns. These similarities raise the question of a possible link between these two phenomena as well concerns about the differential diagnosis and treatment of each problem.
Wozniak et al. (1999) investigated whether children with ADHD are at increased risk of suffering from trauma as well as PTSD and related psychopathology. Their definition of trauma included child abuse as well as other traumatic events like accidents, combat, medical catastrophes, and physical attacks. They concluded that there were no meaningful associations between ADHD, trauma, and PTSD. They did not disaggregate their data by category of traumatic events, however, our examination of their tabulated data reveals that that 7% of their ADHD population had suffered from child abuse (including sexual abuse, physical abuse, and witnessing domestic violence) compared to .1% of their comparison sample. Also, they excluded adopted children, possibly leading to lowered rates of abuse. Thus, their methods may have limited chances for finding links between abuse and ADHD.
Ford et al. (2000) examined the relationship between trauma exposure and both ADHD and oppositional defiant disorder (ODD). After screening admissions in an outpatient psychiatric facility for ADHD and ODD, they assessed children's exposure to trauma and PTSD-related symptoms. Trauma was strongly linked to ODD: 45–73% of the ODD sample had been exposed to physical maltreatment, and 18–31% had been sexually maltreated. In contrast, 25% of the ADHD children were exposed to physical abuse and 11% exposed to sexual abuse. Tellingly, 91% of children with comorbid ADHD and ODD had a history of trauma (Ford et al., 2000). Thus, comorbidity of ADHD and disruptive behavior disorders may be a particularly strong correlate of abuse histories.
Our first purpose was to extend a preliminary, descriptive finding of Hinshaw (2002) by examining whether a carefully diagnosed sample of preadolescent girls with ADHD showed higher rates of documented abuse than a matched comparison sample. Our second and more crucial objective was to document whether the subgroup of girls with ADHD and documented abuse was more impaired, in terms of externalizing and internalizing behavior problems, peer relations, and cognitive functioning, than the non-abused ADHD subgroup. We hypothesized that the ADHD-abused subgroup would display substantial impairments in each domain. A key feature of this investigation is the availability of multi-informant and multi-method data on key impairments. In addition to parent, teacher, and staff ratings, these included objective observations of externalizing behavior, validated self-reports and observations of internalizing behavior, peer sociometrics (as an indictor of social relations), and standardized cognitive tests. Finally, to elucidate relevant interactive processes and mechanisms, we examined whether any established linkages between abuse and peer rejection were mediated by tendencies of the abused subgroup to display aggressive behavior patterns. Because aggressive behavior has been causally linked to the development of peer rejection (e.g., Erhardt & Hinshaw, 1994), we tested whether aggressive behavior might account for association between abuse and negative peer status.
Section snippets
Overview of procedures
The present research was conducted as part of a 3-year, National Institute of Mental Health (NIMH)-funded, series of summer camp investigation of girls with ADHD, held in 1997, 1998, and 1999 (see Hinshaw, 2002, for details). After initial recruitment and screening of participants, written consent was obtained and families came to campus for an extensive in-person evaluation during which assessments of IQ and academic achievement, as well as interviews and checklists of internalizing and
Results
Of the 24 cases with abuse histories, four were comparison girls (4.5% of comparison sample) and 20 were girls with ADHD (14.4% of the ADHD sample). The chi-square test of this difference was significant, p < .05. The odds ratio was 3.5. As shown in Table 2, the ADHD sample had numerically higher rates of all types of abuse, most notably neglect and sexual abuse.
The focus, therefore, shifts to how the abused group of girls with ADHD differs from the girls with ADHD without histories of abuse.
Discussion
We examined the rates of child abuse in a large and diverse sample of preadolescent girls with and without ADHD. First, we found that the girls with ADHD were at increased risk of having abuse histories. Second, those girls with ADHD and a history of abuse were distinct from their ADHD counterparts in terms of their levels of externalizing behavior and peer rejection. Specifically, the abused ADHD subgroup was viewed as significantly more aggressive according to parent, teacher, and peer report
Acknowledgements
We thank the girls and families who participated in our summer research programs and the research coders who diligently aided in the preparation of the data. We give special thanks to Elizabeth Owens for help with data analyses.
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Work on this article was supported by National Institute of Mental Health Grant 45064, awarded to Stephen Hinshaw, and an Underrepresented Minority Supplement to this grant, awarded to Allison Briscoe-Smith.